Facelift Series #12: Deep Plane Facelift w/ Dr. Christopher Surek

0:00 Summer Hardy (00:01): Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. Today's episode in our facelift series is Deep Plane Facelift. What are we talking about in this episode, Dr. Bass? Dr. Bass (00:28): This episode is about the deep plane, what it means anatomically, the different approaches to it, and what things we change in the deep plane during the surgery. This term has generated more discussion in facelifting in the last few years, but also more confusion and distortion, so we wanted to set the record straight a little bit. The deep plane is not a secret, it's not new, it's not magical or necessarily better, but it represents an anatomic portion of the face that is and has been part of most facelifts since the 1980s. To help with this discussion, I've asked an additional guest to join us today. Dr. Christopher Surek is a board certified plastic surgeon in Overland Park, Kansas. He's an assistant professor of anatomy at Kansas City University, as well as a clinical assistant professor of plastic surgery at the University of Kansas Medical Center. He's an expert in facial anatomy, and he's written and lectured extensively on this subject, directing multiple courses and programs for years at the Aesthetic Society meetings, the biggest plastic surgeon society dedicated to aesthetic plastic surgery. (01:55): Welcome to the podcast, Dr. Surek. It's a pleasure to have you with us. Dr. Surek (01:59): Lawrence, I'm happy to be here. I'm honored. I'm looking forward to a great episode. Summer Hardy (02:04): Welcome, Dr. Surek. To start, can you tell us what the deep plane is and how is it important in facelifting? Dr. Surek (02:11): Absolutely. It's a complex question. I think what Lawrence already alluded to is with social media, online marketing, and the competitive market, deep planes become a trigger term that a lot of our colleagues utilize to describe a "long-lasting" or maybe more effective, more dramatic change to the neck and jawline through facelift surgery. Simply put, the deep plane means that you're going deeper than just the subcutaneous tissue, right? So if you just lift the skin by itself, that's just a skin only facelift. But there's two layers we care about in facelift surgery, the skin layer and then a layer deep to it, which has a name called the SMAS. And I teach that to all my patients. I know it's a technical term, but think of it as the bedsheet that wraps around the facial muscles and fat. So when patients look at themselves in the mirror and they look at jowling or vertical lines in their neck, there's a skin component, but really the smash layer is where the action's at. (03:10): And so simply put, a deep plane means you're lifting the skin and this SMAS layer when you're repositioning these tissues and facelift surgery. Summer Hardy (03:21): Okay. What are the main techniques used in the deep plane during facelifting? Dr. Edinger (03:25): There are two main techniques. There's a composite and a bilamellar. There are some variations in these, but mostly these are the two broad categories when we talk about deep plane facelifts. Summer Hardy (03:34): Got it. And what are the main differences between these two? Dr. Surek (03:37): Summer, that's a great question. And you might get different answers depending on what surgeon you talk to, but when you think about those techniques, there's four characteristics that really differentiate the two. So the first is how much skin do you elevate in the operation? In other words, how much skin will you separate from that deeper layer is the first point. The second point is at what point do you enter that deeper layer to get below that SMAS? In other words, where does the surgeon choose to enter the deep plane in order to elevate it? And then the third component is once you've elevated a certain amount of skin and once you've entered the SMAS, then when you're going to reposition it to correct the problem, what vector or direction do you use? In other words, are the skin and the SMAS going the same direction or do the skin and this mass have a different vector or goal as far as direction goes? (04:32): That's the third component. And the fourth component is what do you do with the neck? And I'm sure we'll get into this later on, but those are really, if you look at the literature and you look at all the lectures that are done both in the US internationally, all the debate surrounds those four topics, skin elevation, SMAS entry point, vector of pull and neck maneuvers. Dr. Bass (04:53): And so if you think about what Dr. Surek just said, both techniques are really bilamellar, but they're different in the amount that each of those layers, what we call a lamella, is a layer. They're different in the amount that each of those layers gets manipulated. And so it's not that something's getting left out with either technique, it's just how the layers are getting handled is a little bit different in degree. And as Dr. Surk pointed out, perhaps in direction, although we're going to come back to that issue. Summer Hardy (05:32): Okay, that makes sense to me. So what are the advantages of the composite technique? Dr. Surek (05:37): So for those who utilize the composite technique, you'll hear a variety of quote unquote advantages. First and foremost, the composite facelifters hang their hat, if you will, on the fact that they keep all the layers together as much as possible. So there's less separation of the skin and the SMAS, and so you're pulling everything as one single unit theoretically into a position. So that's a theoretical advantage. The more skin you undermine, occasionally you might see changes in that skin early on, whether it's telangectasias, which is blood vessel appearance or pigmentation, that's debatable depending on the technique and the surgeon, but that is the main proposed advantage of composite is you're keeping all the layers together as much as possible and moving them as a unit. The caveat is that no matter whether it's composite or by lamellar, even if you elevate a little more skin, everything else from that beyond, in other words, toward the nose and mouth, is still a composite flap. (06:37): So the question is how much composite flap do you want to create versus the advantage of having them separated? And we'll get into that in a little bit. Dr. Edinger (06:45): And Dr. Surik, is there any proof in the advantage? You were mentioning some talks about telangiectasia, skin changes, things like that, but there are any proof and advantages of really keeping those two units together as one? Dr. Surek (06:56): Nothing that I would consider level one through three evidence, meaning that large case studies with a lot of scientific analysis. A lot of what we hear in aesthetic surgery is truly anecdotal or experience-based. And so I think, as I mentioned, there's multiple ways to skin a cat. All surgeons have their own artistic component to their surgery, but I wouldn't say that there is a statistically significant data proof that the composite has an advantage over other operations. Dr. Bass (07:26): And part of the reason this is so difficult to study and what you would like to study is the degree of correction, how much aging change you reverse or eliminate, and the durability of correction, how long that improvement lasts. And other things that get talked about with less skin undermining is maybe a smaller rate of small hematomas, that's a little easier to study. And there's a lot of claim about how much recovery period using each technique with proponents on both sides saying that it may lead to shorter recovery, so go figure. And that really probably varies more with the surgeon and their individual operative technique and patient-to-patient variation. And that's another reason why recovery is hard to study because there is a lot of variation from person to person and how much bruising takes place, how much swelling separate from any difference in technique. And so you need a very large group of patients to even that all out and answer a question about improvement. (08:37): In terms of grading the degree of correction, likewise, that's very subjective. There's no good quantitative way to study this and grade the amount of improvement in a comparable way, especially at different sites with different surgeons. Summer Hardy (08:56): Okay. And now what about the flip side? What are the disadvantages or risks of the composite technique? That's Dr. Surek (09:03): A good question. Yeah, I have a slight bias because I prefer the biomellar technique. The disadvantages to composite, in my opinion, number one, a lot of times you're approaching the SMAS from a more anterior point, meaning you're getting closer to the facial nerve branches. Not saying you're going to disrupt them, but it is a slightly more aggressive line in some scenarios getting into that deep plane. So that's one potential advantage. Again, there are a lot of composite faces who do great work that have minimal issues, but anatomically, that's just a fact. The entry point's more forward. The second component to me is the vector of pool. I'm a big believer that the skin and the SMAS need to be repositioned in different vectors. And in my hands, a composite flap does not allow me to do that as effectively. And to be frank, when I look at a lot of composite videos and I see people present composite surgery, it's not uncommon that once they've repositioned the SMAS in skin, they end up undermining and freeing up skin to create a more vertical vector or a more oblique vector. (10:08): So I think the vectors of pool is the big differentiating difference between the two, in my opinion. And for me, I prefer in the majority of patients, separate vectors between the SMAS and the skin, which is harder to achieve in my hands with a composite technique. Dr. Edinger (10:25): Is there any data on nerve injuries, Dr. Surek? Dr. Surek (10:28): Again, it's going to be anecdotal. I mean, you're going to hear people who see patients who've had complications from composite that might be nerve related, but I'm sure on the flip side, there'll be patients who've had bilamellar that may have had a nerve injury. So to my knowledge, again, there's not a very strong level of evidence study that would claim or prove that nerve injury is increased with one or the other. Dr. Edinger (10:54): Okay. And then you mentioned that the bilamellar approach really allows you to pull the skin and the SMAS in separate vectors. Are there any other main advantages that you see to that technique? Dr. Surek (11:03): Well, that's the first advantage. The second advantage is you are entering the SMAS a little bit more posterior or closer to the ear, which for me allows me to establish what I feel to be a safer plane for me. It allows me to establish a plane of separation. So as I get closer to where the facial nerve branches are arising in the deep plane, I feel as if I have a pretty good idea of where they are and how to navigate away from them. And the other thing is, in a large majority of patients, especially the older they get with skin laxity, some patients really require wide skin undermining to get that excess loose skin out. In other words, you really got to separate that and elevate it, and it does help maximize skin removal in a subset of patients if you do bilamellar. Dr. Bass (11:48): And I think those are really, really important points. If you enter the SMAS relatively close to the ear, far back on the cheek, the SMAS is thicker in that area. You have a well-established dissection plane as you come past the parotid gland into a thinner SMAS and very close to facial nerve branches area. So you're established and have a pathway rather than starting right in that somewhat more treacherous zone. But you do still come out into that area, for example, with an extended SMAS, flap elevation, and I've seen those little branches of the facial nerve many times, but you already are traveling along a pathway by the time you get there. I think the biggest thing to me is what you said about the vectors of pull. And part of the teaching about facial aging is that all the different components of the face, they're shrinking, they're descending, they're loosening, but each of them does it differently, a different amount at a different rate. (13:01): And so to say that we want to keep what was confluent in youth and has now become individual sags and bags, that we want to keep that together and elevate it as a composite. I think that works great if you're in the early stages of aging, but as you get older and that those separations become more pronounced, I think each component, the SMAS layer, the skin layer in the face, the platysma and the skin layer in the neck, all four of those components may need to go in a different direction for optimum correction. And I think bilamellar allows the flexibility to do that. And I also couldn't agree more about the wide undermining. A younger patient may not need a great deal of undermining as long as some of the fixation ligaments are released, but the older patients may have considerable redundant skin relatively medially in the face, close to the nose, close to the fold between the cheek and the upper lip, in the gel area. (14:12): And it can be tough to fully re-drape that without undermining directly under the skin. So I'm with you on a lot of those issues. Summer Hardy (14:23): Is one technique better than the other? Dr. Surek (14:27): Again, I think that's a hard question to answer. A lot of things in plastic surgery, there's multiple ways to achieve the same result. And so I think it's the surgeon's comfort level, their own personal artistic, and the outcome that they can achieve that's best in their hands. And so I know a lot of great surgeons that do composite. I know a lot of great surgeons do bilamellar. I don't think one necessarily better than the other. It depends on what works best in your hands. And for someone who's a high volume face lift surgeon, they can achieve good results with either one, in my opinion, if they've mastered it. And again, paying attention to the details that Lawrence just mentioned. Dr. Edinger (15:04): And maybe even more importantly, do you think there are any particular techniques, or sorry, are there any particular types of patients who might benefit from one approach or the other? Dr. Surek (15:13): That's a good question. I would say I still believe that bilamellar can cross all categories of ages. You may limit a little of your skin undermining, but I personally think when we think about patients, we have chronological age, which is how old you are, and anatomic age, which is how you look at atomically. And that's different, right? Some 40-year-olds look 50, some 50-year-olds look 40. And so I'm not treating the chronological age, I'm treating the anatomical age. And facial aging, although it happens to all of us, which is unfortunate but true, it's predictable. And so for me, whether you're 42 or 72, my objectives are still pretty similar. I want to get the SMAS back into a vertical position. I want to bring the jaw volume back into the cheek because again, the SMAS is the vehicle that brings the tissue back up to where they were. (16:05): And then I want to redrape the skin appropriately so you don't get a wind swept effect. So some would argue that composite flap could work for a younger patient compared to bilamellar. I still believe, and I think Lawrence is right, there might be a component to it as far as ligament release, but the principles remain the same. And so for me, I'm treating the anatomy and I follow the anatomy. And so in the majority of my patients, bilamellar gets me the better result. Dr. Bass (16:31): I think that's right, and that's generally my approach, but it's interesting that I think you mentioned that deep plane or composite is not as vertical in approach of repositioning, but I think that depends on which deep plane surgeon or composite surgeon you're asking. And we've had commentators on the podcast before we started this facelift series who touted deep plane vertical motion in the mid-face as one of the advantages of the technique. But I think it's possible to select the vector of motion you want, certainly with a bilamellar approach and to a certain extent with a composite approach, although that vector with the composite approach is going to be the same for both tissue layers where it can be different with the bilamellar approach. Dr. Edinger (17:30): And then I know plastic surgeons are increasingly advocating deep techniques in the neck. Does that commit you to one or another deep plane technique in the face or are deep neck techniques compatible with both the composite and the bilamellar approaches? Dr. Surek (17:43): You can certainly do both. If you're going to do deep neck work, you can make it work with either a bilamellar or a composite technique. Again, theoretically, if someone's a composite facelift or they may have their own advantages to it. What I like about the bilamellar approach is typically I do my neck last, and so I'll open up both sides. I'll do the skin and it's mass and I will undermine all the way to where I'm going to approach the neck. So that way when I enter the neck, everything's already undermined for me. And then I have a beautiful visual of the platysma muscle, which is the SMAS equivalent in the neck, and I am able to get good exposure. And when it comes to deep neck work, you need really good exposure because you're working in a small window. And so for me, those are proposed advantages in the bilamellar approach, but you certainly can do deep neck work in a composite as well. Dr. Bass (18:31): And there's been a big push towards aggressive treatment of the neck in the deep plane. Perhaps that's more marketing than it's a real change in surgical activity. But I'm curious to hear, Dr. Surek, what your perspective is. I know you work with deep neck techniques. Most of us do them to some extent. We know the anatomy, but is it something you're performing on most of your necks or is it something that you perform selectively? Dr. Surek (19:03): It's a good question. I do it selectively. I don't do it on everybody. And again, I'm following the anatomy. If someone's at thin neck and they don't have a lot of visible deep neck tissue, either on preoperative photographs, video or examination, then I typically will not do deep neck work. If someone has a full neck where they clearly have deep neck volume that is contributing to the aesthetics that are bothering them, which means the fullness of their neck, the turkey neck or the obtuse, meaning that blunted angle between the chin and the neck, then yes. Then if they're a candidate for it, I do think deep neck has a significant role for a lot of patients, but I do not believe it has to happen in everybody.

0:40 Dr. Bass (19:44): And just as a variation of that question, maybe comment on what the primary components of deep neck are, and if you decide to do deep neck, do you always do all of them or you just cherry-pick depending on what features you notice in the patient? Dr. Surek (20:02): That's a good question. I believe the deep neck is an all or nothing phenomenon. So in other words, when you get below the neck muscle of platysma, if you only evacuate tissue centrally and not laterally, that can create indentation over time because now as the volume retracts, remember, the skin's going to follow the path to least resistance. So part of the component of a deep neck and why we can do it isolated in some people without a true facelift is that the skin's going to follow the path to less resistance and retract back where the volume is removed. But as far as I'm concerned, the deep neck is all or nothing. If you're going to do deep neck work, then you need to address the fat both centrally and laterally. The sagging salivary gland, which is a big part of deep neck work. In other words, you're not going to remove the gland entirely, but you're going to trim it so that it's level with the jawline. (20:51): That salivary gland is a minor one. It does not have a significant contribution to saliva like the parotic gland. So most patients do just fine with it being removed. And then occasionally the muscle that separates the fat and the gland can be bulky, and so you trim that. So if I'm going to go into the deep neck, I do believe in the majority of cases I'm going to treat all three components. Dr. Bass (21:12): Yeah, it's interesting. And I understand what you're saying. In my hands, I am more selective and a lot of times I'm working on the platysma and it's usually something I decide intraoperatively that despite you start to see as you're developing your corset platysmoplasty or whatever variation of that you might do to bring the platysma back into continuity, that there's still a fullness and bowing. In the very heavy neck, you know ahead of time that you're going to be chasing more than just the superficial structures. But I've had the experience where you're bringing it together and you realize that's not going to sit flat over time, and now you need to get in the deep neck and do somewhat more than what you were initially intending or you're not going to get the shape you want. Summer Hardy (22:05): And Dr. Bass, can you share your takeaways? Dr. Bass (22:08): Sure. So in this discussion, I think we've seen that both composite and bilamellar, or what I sometimes call multiplanar techniques, enter the deep plane of the face, release connective tissue attachments or fixation points that allow us to reposition and rejuvenate the face during the facelift. The first technique, the composite technique creates a composite or combined flap of SMAS with overlying fat and skin that gets repositioned as a unit. The second technique or bilamellar technique creates individual skin and smash flaps, which are individually tailored and repositioned. There are other techniques that don't enter the deep plane, such as plication and smastectomy techniques and suture suspension techniques like the MaxLift, and we'll discuss these particular techniques in a different episode of the facelift series. Both deep plane techniques are in widespread use by experienced facelift surgeons who are getting outstanding results. It's difficult to prove any of the theoretical advantages connected with each technique. (23:27): It's very clear that both approaches work. The quality of your result in a facelift is probably more about the skill and experience of the surgeon than the particular technique that's selected. In other words, how well a technique is performed affects the result a lot more than which one of these two techniques is selected. Finally, it's really important to remember that all facelifts are customized for your individual face. So we're starting with the basic technique selected based on what we find on exam, but then that gets customized during surgery to account for your individual findings and to account for differences between the two sides of the face. I'd like to thank Dr. Surek for joining us. This was a great discussion. I think you really boiled it down in such a clear disposition about what's going on with these techniques, making it easy for the listeners to understand. Dr. Surek (24:33): Well, thank you very much. I was honored to be on here. Dr. Edinger (24:35): Thank you, Dr. Surek. Thank you, Dr. Bass. Summer Hardy (24:38): Thank you, Dr. Surek for sharing your anatomic expertise on this controversial facelift topic, and thank you to Dr. Edinger and Dr. Bass for adding their perspectives. I know the listeners will get a lot out of this discussion. Thank you for listening to the Park Avenue Plastic Surgery Class Podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.